Electronic health records (EHR) to improve medication compliance

A recent report in the Annals of Internal Medicine on the characteristics of prescriptions that are abandoned at the pharmacy raise the question of (1) how to ensure that people actually pick up their prescriptions, and (2) how to make sure that people actually take the medications that are prescribed.

What role does modern Electronic Health Record (EHR) technology play in this question?

A study by the non-profit New England Healthcare Institute (NEHI) in 2009 estimated that non-adherence to medications cost the healthcare system $290 billion annually in avoidable medical spending every year. So what are the barriers?

The Annals article showed that, eventually (within 1 month), most prescriptions are filled – although the study looked almost exclusively at the prescriptions given to patients with insurance. The medication abandonment rate has not been studied in as thorough a way for patients who lack insurance (or who have very large out-of-pocket deductibles for prescriptions). However, prescriptions given to a patient for the first time, prescriptions that were delivered to the pharmacy electronically, and prescriptions for which the patients have a higher copay were more likely never to be picked up.

It is a little counter-intuitive to find that e-prescriptions had a higher never-picked-up rate (referred to as “primary non-adherence”) than written (or printed) prescriptions – after all, the patient experience with a paper prescription is that it usually involves a two-step process at the pharmacy: (1) present the prescription, so the pharmacist can begin processing it, and (2) picking up and paying for the filled prescription (sometimes needing a second visit to the pharmacy, depending on wait times). Electronic prescriptions eliminate the first step, so that the visit to the pharmacy is simply to pick up the med (in theory).

However, there is something to be said for having a piece of paper in one’s hand to serve as a prompt to go to the pharmacy – and perhaps giving a patient a printed receipt for the e-prescribed medication (rather than simply tell the patient “go to the pharmacy and pick up your meds”) will help. Single stop at the pharmacy (Rx is waiting), aided by a manual prompt (paper receipt) – such an approach has not yet been studied, but would be interesting.

A study published this year in the Journal of General Internal Medicine looked at the fill-rates of electronically-delivered prescriptions. In that study, the primary non-adherence rate was about 20%, though prescription fill-rates were better for primary care physicians, and for patients less than 18 years of age. The biggest predictor of primary non-adherence was medication class: new prescriptions for chronic conditions (like hypertension, hyperlipidemia and diabetes) were the most likely to never get picked up.

This pattern also correlates with the rate of maintaining adherence to a prescription – the “secondary non-adherence” (or “medication compliance”) rate, that frustrates physicians. Maintenance medications for chronic conditions are the area where the lowest long-term compliance is seen. Very different than medications for acute illnesses.

This is in contrast to the experience at Kaiser, where the primary non-adherence rate is around 5%. Perhaps, as speculated in a review in the New York Times, this is because of the ease-of-process for prescriptions in the integrated Kaiser delivery system – same building, electronic prescribing, quick pick-up (on the way out from the clinic visit), low co-pays.

How can modern EHR technology help this situation? Firstly, it is important to recognize that there is no panacea, and there will always be some non-zero rate of prescription abandonment. However, barriers to getting the medications prescribed can be reduced by EHR technology. Issues that come to mind are:

1. Formulary checking (in other words, cost-checking from the patient-experience standpoint) will help physicians prescribe the most-likely-to-be-filled option.
2. Electronic prescribing can reduce in-pharmacy wait times, though generating a paper receipt in the clinic may provide a good prompt/reminder for the patient to go to the pharmacy (and remind the patient of which pharmacy the prescription was sent to)
3. Reports from the EHR showing refill events, so that gaps in filling maintenance medications can be identified, and those patients can receive active outreach from the practice (reminding to come in and review their medications). Health plans try to do this, but their reports are very after-the-fact, and don’t have the kind of impact that similar lists generated in-house by the EHR system would have.

Clearly, the evolution of EHR technology will help provide the tools needed for healthcare delivery teams to reduce issues of medication non-adherence (primary and secondary). This is a work-in-progress. Further, as such tools become widely adopted (in this era of Meaningful Use), we may actually see a reduction in the avoidable health costs that medication non-adherence creates.

Robert Rowley is a family physician and CMO of Practice Fusion. He blogs at EHR Bloggers.

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Baldedoc

Awesome, more data that will be turned into unfunded action items that pcp’s will be made responsible (either by liability pressure or by pay for performance hurdles) for. Tell me again why doctors aren’t rushing out to sign up for emrs? Boy I’m glad I’m a surgeon.

Adam Rothschild, M.D., M.A.

While your statement is true in that “It is a little counter-intuitive to find that e-prescriptions had a higher never-picked-up rate”, I wonder whether there might be a confounding issue here, specifically e-prescriptions abandoned not by the patient but by the prescribing physician. It turns out that Surescripts does not require EMR/eRx vendors to implement the “cancel Rx” transaction in order to be certified, so many vendors have not implemented it. From a practical perspective, this means that sometimes a physician e-prescribes a prescription to a given pharmacy only to have the patient change his mind and decide that he wants it e-prescribed to a different pharmacy. The physician will usually just send a new e-prescription to the new pharmacy and never bother to cancel the prescription at the previous pharmacy since it would require a phone call. If this practice is common enough, it would throw off the numbers to accentuate your stated paradox. Just a thought.

Marc Gorayeb, MD

Explain to me again how EHR makes the practice of medicine more efficient? And if you reply that you must sacrifice efficiency for improved patient care, explain to me why the author is still reduced to SPECULATING how EMR MIGHT improve patient care. As he so clearly points out, the existing studies provide no such evidence. (Horrors! it’s all so counter-intuitive).